Why More and More Patients Go Broke? NY State Verdict: Guilty! #1 = Insurers, #2 = Providers

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NY Governor Andrew M. Cuomo announced on March 7, 2012 NY State Findings and Recommendations of NY DFS Investigations of The Top Healthcare Crisis Today - Unexpected Out-Of-Network Medical Costs. ERISAclaim.com Offers Webinars To Examine NY “Guilty” Verdict and Solutions.

The NY reform is the USA reform when about 77% of insured Americans purchased out-of-network coverage in private industry, says Dr. Zhou

NY State Governor Andrew M. Cuomo announced on March 7, 2012 that the Department of Financial Services (DFS) is investigating unexpected out-of-network medical costs affecting New Yorkers across the state, many of whom cannot afford to pay out-of-pocket expenses. In addition, DFS released a report finding that insurance companies are the first one to be responsible, and the healthcare providers are also responsible for unexpected out-of-pocket expenses driving so many patients into bankruptcy. The report finds an overwhelming need for increased transparency from insurers and medical service providers, and improved consumer protection measures to ensure that New Yorkers stop receiving unexpected bills. (http://www.dfs.ny.gov/about/press/pr1203071.htm)

ERISAclaim.com is now offering webinars to examine the NY DFS specific findings and recommendations, and to provide practical solutions for all out-of-network providers to voluntarily and proactively comply with all NY State Government patient protection recommendations: full disclosures with out-of-network ACA discount protection under new federal health reform law PPACA (ACA, in short), Patient Protection and Affordable Care Act.

The full NY DFS report, titled “An Unwelcome Surprise: How New Yorkers Are Getting Stuck with Unexpected Medical Bills from Out-of-Network Providers”, is available at http://www.governor.ny.gov/assets/documents/DFS%20Report.pdf.

“Governor Andrew M. Cuomo did it again for USA, after he fixed nation’s UCR with Ingenix crisis, for not only New York State but entire USA. This report provides the real verdict for the top US healthcare crisis today faced by every American, and resolved a mystery for why “Harvard researchers say 62% of all personal bankruptcies in the U.S. in 2007 were caused by health problems—and 78% of those filers had insurance”, says Dr. Jin Zhou, President of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance. (http://www.businessweek.com/bwdaily/dnflash/content/jun2009/db2009064_666715.htm)

“Governor Cuomo may also have demystified a 2012 CNN Money report that more and more doctors are going broke today, when some insurers’ profits went up 73% and 78% of insured patients are 62% of all personal bankruptcies,” commented Dr. Zhou. (http://online.wsj.com/article/BT-CO-20120201-713202.html),

According to the NY DFS Press release and 41-page full report, insurer companies are paying far less for health retail prices (UCR) than whole discounted rates (PPO) (http://www.dfs.ny.gov/about/press/pr1203071.htm):

“Insurers are paying less of the cost of out-of-network care: The investigation found that insurers are moving to a system that greatly increases how much it costs consumers when they are treated out-of-network. To determine what they would pay for out-of-network care, most insurers used to use what is known as the usual and customary rate (UCR), which is supposed to be an average of actual bills for a procedure in that region. But now most are using the Medicare rate, which decreases how much insurers pay by as much as half or more in some cases. Insurers make this change hard for consumers to understand, because some are told they are going from 80% of the usual and customary rate to 140% of Medicare, which sounds like an improvement, but is not.

In one case, a patient was approved for a surgery using the usual and customary rate. The insurer said it would pay $31,978 of the $47,685 cost. Before the surgery could be done, the insurer changed to a Medicare Fee Schedule and the insurer would only pay $4,864.62.”

“And insures may often sue out-of-network providers if they don’t collect entire $47,685 even if insurers may only pay $4,864.62. Aetna recently sued seven surgical centers in California to stop the centers from waiving coinsurance payments required for out-of-network providers,” explained Dr. Zhou. (http://www.fiercehealthpayer.com/story/aetna-sues-surgery-centers-overbilling/2012-02-09)

In the final NY DFS report, Governor Cuomo concluded the failure of the insurer’s disclosures mainly and directly caused the unexpected out-of-network medical bills: (page 13 of 41 at http://www.dfs.ny.gov/about/press/pr1203071.htm)

“The failure of insurers to provide benchmark data to allow consumers to compare out-of-network benefits has at least two detrimental consequences. First, it leads to surprise and anger for consumers who suddenly realize how little their insurance pays for out-of-network provider bills. Second, it contributes to inefficiency in the health insurance market. If consumers are unable to accurately compare apples to apples for out-of-network benefits, they may well, for instance, purchase coverage on the mistaken belief that 140% of Medicare is better coverage than 80% of UCR.”

Governor Cuomo calls for reform by health plans and providers in compliance with PPACA:

“Nonetheless, there is room for improvement. Reforms will require health plans and health care providers to make changes in current policies and practices. Some of those improvements may include enhanced disclosure, network adequacy requirements, standards for coverage of out-of-network health care services, and prohibitions on excessive charges for emergency health care services. As New York prepares for federal health care reform under the federal Affordable Care Act, we should take this opportunity to improve on problems of surprise bills from out-of-network providers. Working families, employers, and businesses located throughout the state (insurers and non-insurers alike) deserve no less.” (Page 39 of 41 at http://www.dfs.ny.gov/about/press/pr1203071.htm)

The NY reform is the USA reform when about 77% of insured Americans purchased out-of-network coverage in private industry, says Dr. Zhou. (Page 11 of 167 at http://stats.bls.gov/ncs/ebs/detailedprovisions/2010/ebbl0047.pdf)

To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:

Located in a Chicago suburb in Illinois, ERISAclaim.com offers free webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.

For any questions, please contact Dr. Jin Zhou, president of ERISAclaim.com, at 630-808-7237.

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